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COMMUNITY SERVICE (Organizations; offices held; indicate past or present): 1. 3. 2. 4. MILITARY SERVICE RECORD Applicable laws require the disclosure of any existing or potential conflicts of interest. If you have any conflicts of interest that may raise concerns, please describe them below: Some of the boards and commissions require the filing of a Financial Disclosure Statement. If required, would you comply? ❑ Yes ❑ No Have you ever been convicted of a violation of the law? ❑ Yes ❑ No If yes, explain. NOTE: A conviction record will not be deemed a basis of denial for consideration unless the offense is related to the board or commission for which you have applied. PERSONAL REFERENCES 1. 2. I hereby acknowledge and attest that the information I have provided is true and accurate to the best of my knowledge and belief. I waive any right to privacy and authorize the Office of the Mayor, along with its employees, agents, and assigns, to investigate and obtain information regarding my suitability to serve as an appointee of the County of Hawai'i. I also waive any claims against the County of Hawai'i, its officers, employees, agents, assigns, and any person or entity providing information, for any liability or damages arising from the dissemination or acquisition of this information. SIGNED BY The information provided in this application is confidential and intended exclusively for use by the Mayor's Office in matters related to boards and commissions. For any questions, please contact malairmneda. hawahcount I y or call 808 961-8211. PLEASE RETURN THE COMPLETED FORM TO: ATTN: BOARDSAND COMMISSIONS OFFICE OF THE MAYOR,COUNTY OF HAWAI'I 25 AUPUNI STREET,Suite 2603 HILO, HI 96720 Or Fax the Form to: 808-961-6553 *This information is requested for the purpose of conducting a criminal history check only.